Reference ranges for and determinants of right ventricular area in healthy adults by two-dimensional echocardiography

High-echoic line tracing of transthoracic echocardiography accurately assesses right ventricular enlargement in adult patients with atrial septal defect

Accurate measurement of right ventricular (RV) size using transthoracic echocardiography (TTE) is important for evaluating the severity of congenital heart diseases. The RV end-diastolic area index (RVEDAi) determined using TTE is used to assess RV dilatation; however, the tracing line of the RVEDAi has not been clearly defined by the guidelines. This study aimed to determine the exact tracing method for RVEDAi using TTE. We retrospectively studied 107 patients with atrial septal defects who underwent cardiac magnetic resonance imaging (CMR) and TTE. We measured the RVEDAi according to isoechoic and high-echoic lines, and compared it with the RVEDAi measured using CMR. The isoechoic line was defined as the isoechoic endocardial border of the RV free wall, whereas the high-echoic line was defined as the high-echoic endocardial border of the RV free wall more outside than the isoechoic line. RVEDAi measured using high-echoic line (high-RVEDAi) was more accurately related to RVEDAi measured using CMR than that measured using isoechoic line (iso-RVEDAi). The difference in the high-RVEDAi was 0.3 cm²/m², and the limit of agreement (LOA) was - 3.7 to 4.3 cm²/m². With regard to inter-observer variability, high-RVEDAi was superior to iso-RVEDAi. High-RVEDAi had greater agreement with CMR-RVEDAi than with iso-RVEDAi. High-RVEDAi can become the standard measurement of RV size using two-dimensional TTE.

Predictive echocardiographic factors of severe obstructive sleep apnea

Introduction

obstructive sleep apnea (OSA) is a common chronic pulmonary disease, characterized by repetitive collapse of the upper respiratory airways, leading to oxygen desaturation. This condition is recognized to be associated with cardiovascular disease. Several studies have shown the effects of OSA on both geometry and cardiac function, with conflicting results. We aimed to investigate the relationship between echocardiographic abnormalities and the severity of OSA.

Methods

this is a cross-sectional single center study including patients, without any cardiovascular or pulmonary comorbidities, with polygraphy proven OSA. All participants underwent a detailed transthoracic echocardiography (TTE).

Results

a total of 93 patients were included in the study, with 62.2% (n=56) females. According to the apnea hypopnea index (AHI), patients were divided into two groups: mild to moderate OSA (5≤ AHI< 30/H) and severe OSA (AHI≥ 30/H). There were no differences in baseline characteristics between the two groups. The assessment of echocardiographic parameters demonstrated that severe OSA have a higher left ventricular end-systolic (LVES) (47.6±7.2 VS 46.2±4.7), left ventricular end-diastolic (LVED) (31.3±6.2 VS 28.9±4.5) diameters and interventricular septum (IVS) thickness (12.7±2.4 VS11.7±2.5) diameters rather than mild to moderate OSA without a significant difference between the two groups. Furthermore, severe OSA patients had lower mean value of left ventricular ejection fraction (LVEF) and fractional shortening (FS) equal to 62.1±9.7 and 32.5±6.3 respectively. The difference between the two groups was not statistically significant. However, a significant association was shown between severity of OSA and left ventricular (LV) diastolic dysfunction, right ventricular internal diameter (RVID) and systolic pulmonary artery pressure (sPAP), with p=0.05, p=0.05 and p= 0.03 respectively. The RVID was also independently associated to the severity of the OSA (aOR 1.33, 95%CI: 0.99-1.79; p=0.05).

Conclusion

using bidimensional echocardiography showed a relationship between severe OSA and right ventricular parameters (diastolic dysfunction and RVID) and sPAP.

Right Heart Size and Right Ventricular Reserve in Pulmonary Hypertension: Impact on Management and Prognosis

Various parameters reflecting right heart size, right ventricular function and capacitance have been shown to be prognostically important in patients with pulmonary hypertension (PH). In the advanced disease, patients suffer from right heart failure, which is a main reason for an impaired prognosis. Right heart size has shown to be associated with right ventricular function and reserve and is correlated with prognosis in patients with PH. Right ventricular reserve, defined as the ability of the ventricle to adjust to exercise or pharmacologic stress, is expressed by various parameters, which may be determined invasively by right heart catheterization or by stress-Doppler-echocardiography as a noninvasive approach. As the term "right ventricular contractile reserve" may be misleading, "right ventricular output reserve" seems desirable as a preferred term of increase in cardiac output during exercise. Both right heart size and right ventricular reserve have been shown to be of prognostic importance and may therefore be useful for risk assessment in patients with pulmonary hypertension. In this article we aim to display different aspects of right heart size and right ventricular reserve and their prognostic role in PH.

The Obesity Paradox in Patients with Significant Tricuspid Regurgitation: Effects of Obesity on Right Ventricular Remodeling and Long-Term Prognosis

BACKGROUND

Obesity may cause right ventricular (RV) remodeling due to volume overload. However, obesity is also associated with better prognosis compared with normal weight in patients with various cardiac diseases. The aim of this study was to assess the impact of obesity on RV remodeling and long-term prognosis in patients with significant (moderate and severe) tricuspid regurgitation (TR).

METHODS

A total of 951 patients with significant TR (median age, 70 years; interquartile range, 61-77 years; 50% men) were divided into three groups according to body mass index (BMI): normal weight (BMI 18.5-24.9 kg/m²), overweight (BMI 25-29.9 kg/m²), and obese (BMI ≥ 30 kg/m²). Patients with congenital heart disease, peripheral edema, active endocarditis, and BMI < 18.5 kg/m² were excluded. RV size and function for each group were measured using transthoracic echocardiography and compared with reference values of healthy study populations. The primary end point was all-cause mortality. Event rates were compared across the three BMI categories.

RESULTS

Four hundred seventy-six patients (50%) with significant TR had normal weight, 356 (37%) were overweight, and 119 (13%) were obese. RV end-diastolic and end-systolic areas were larger in overweight and obese patients compared with normal-weight patients. However, no differences in RV systolic function were observed. During a median follow-up period of 5 years, 358 patients (38%) died. Five-year survival rates were significantly better in overweight and obese patients compared with patients with normal weight (65% and 67% vs 58%, respectively, P < .001 and P = .005). In multivariate analysis, overweight and obesity were independently associated with lower rates of all-cause mortality compared with normal weight (hazard ratios, 0.628 [95% CI, 0.493-0.800] and 0.573 [95% CI, 0.387-0.848], respectively).

CONCLUSIONS

In patients with significant TR, overweight and obese patients demonstrated more RV remodeling compared with patients with normal weight. Nevertheless, a higher BMI was independently associated with better long-term survival, confirming the obesity paradox in this context.

Supervised Exercise Training in Patients with Chronic Thromboembolic Pulmonary Hypertension as Early Follow-Up Treatment after Pulmonary Endarterectomy: A Prospective Cohort Study

BACKGROUND

Data on exercise training in chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary endarterectomy (PEA) as well as data on clinical and haemodynamic changes shortly after PEA are lacking.

OBJECTIVE

The objective of this prospective study was to analyse the safety, feasibility, and the effectiveness of combined supervised inpatient rehabilitation in patients with CTEPH directly after PEA.

METHODS

CTEPH patients started a 19-week rehabilitation program (3 weeks as inpatients and continued at home for another 16 weeks) with supervised exercise training as follow-up treatment shortly after PEA. Haemodynamics were assessed by right heart catheterisation before PEA and 22 weeks after PEA. Non-invasive assessments as transthoracic echocardiography and 6-min walking distance (6MWD) were performed before PEA and after 3 (that is, beginning of rehabilitation), 6, and 22 weeks following PEA. Adverse events were recorded throughout the study.

RESULTS

Forty-five CTEPH patients were included (49% female, 57.6 ± 12.4 years old, 60% WHO functional class III). Rehabilitation was started 3.3 ± 0.9 weeks after PEA. Exercise training was well tolerated in all patients without severe side effects. Haemodynamics measured by right heart catheterisation significantly improved from pre-PEA to 22 weeks post-PEA in cardiac output (+1.2 ± 1.5 L/min, 33.4%, p = 0.001) and mean pulmonary arterial pressure (-19 ± 13 mm Hg, -39.6%, p < 0.0001). Right heart size measured by echocardiography, 6MWD, quality of life, and oxygen saturation significantly improved not only within the first 3 weeks after PEA but also during the following 19 weeks of exercise training.

CONCLUSIONS

Supervised exercise training was feasible as early follow-up treatment after PEA. Further controlled studies are needed to discriminate the effects of PEA and early follow-up rehabilitation.

TRIAL REGISTRATION

The study was registered at clinicaltrials.gov (NCT01393327) on July 13, 2011. The study start date was January 2010, and completion date was December 2013.

Normal basic 2D echocardiographic values to screen and follow up the athlete's heart from juniors to adults: What is known and what is missing. A critical review

In the last few years, multiple echocardiographic nomograms have been published. However, normal values calculated in the general population are not applicable to athletes, whose hearts may be enlarged and hypercontractile. Accordingly, athletes require specific nomograms. Our aim is to provide a critical review of echocardiographic nomograms on two-dimensional (2D) measures for athletes. We performed a systematic search in the National Library of Medicine for Medical Subject Headings and free text terms including echocardiography, athletes, normal values and nomograms. The search was refined by adding the keywords heart, sport, elite, master, children and young. Twenty-eight studies were selected for the final analysis. Our research revealed that currently available ranges of normality for athletes reported by different authors are quite consistent, with limited exceptions (e.g. atria, aorta). Numerical and methodological limitations, however, emerged. Numerical limitations included a limited sample size (e.g. < 450 subjects) of the population assessed and the paucity of data in women, non-Caucasian athletes, and junior and master athletes. Some data on M-mode measurements are available, while those for some specific structures (e.g. left atrial (LA) area and volumes, right ventricular diameters and aorta) are limited or rare (e.g. LA area). There was heterogeneity in data normalization (by gender, sport type and ethnicity) and their expression was limited to mean values (Z-scores have rarely been employed), while variability analysis was often lacking or incomplete. We conclude that comprehensive nomograms using an appropriate sample size, evaluating a complete dataset of 2D (and three-dimensional) measures and built using a rigorous statistical approach are warranted.

EXPRESS: Statement on imaging and pulmonary hypertension from the Pulmonary Vascular Research Institute (PVRI)

Pulmonary hypertension (PH) is highly heterogeneous and despite treatment advances it remains a life-shortening condition. There have been significant advances in imaging technologies, but despite evidence of their potential clinical utility, practice remains variable, dependent in part on imaging availability and expertise. This statement summarizes current and emerging imaging modalities and their potential role in the diagnosis and assessment of suspected PH. It also includes a review of commonly encountered clinical and radiological scenarios, and imaging and modeling-based biomarkers. An expert panel was formed including clinicians, radiologists, imaging scientists, and computational modelers. Section editors generated a series of summary statements based on a review of the literature and professional experience and, following consensus review, a diagnostic algorithm and 55 statements were agreed. The diagnostic algorithm and summary statements emphasize the key role and added value of imaging in the diagnosis and assessment of PH and highlight areas requiring further research.

Echocardiographic evaluation of the right ventricular dimension and systolic function in dogs with pulmonary hypertension

Background

Right ventricular (RV) enlargement and dysfunction are associated with prognosis in humans with pulmonary hypertension (PH).

Hypothesis/Objectives

To assess RV size and systolic function in dogs with PH and to determine if they are associated with disease severity and right‐sided congestive heart failure (R‐CHF).

Animals

89 dogs with PH and 74 healthy dogs.

Methods

Prospective observational study. PH was classified according to the tricuspid regurgitation pressure gradient. RV end‐diastolic area (RVEDA) index was calculated as RVEDA divided by body surface area. RV systolic function was assessed with the tricuspid annular plane systolic excursion (TAPSE) and the RV fractional area change (FAC) normalized for body weight (TAPSEn and FACn, respectively).

Results

RVEDA index was higher in dogs with moderate PH (10.8 cm²/m²; range, 6.2‐14.4 cm²/m²) and severe PH (12.4 cm²/m²; range, 7.7‐21.4 cm²/m²) than in those with mild PH (8.4 cm²/m²; range, 4.8‐11.6 cm²/m²) and control dogs (8.5 cm²/m²; range, 2.8‐11.6 cm²/m²; P < .001). RVEDA index was significantly higher in dogs with R‐CHF (13.7 cm²/m²; range, 11.0‐21.4 cm²/m²) than in dogs without R‐CHF (9.4 cm²/m²; range, 4.8‐17.1 cm²/m²; P < .001). The severity of tricuspid regurgitation (TR) was the only independent predictor of the RVEDA index (P < .001). TAPSEn and FACn were not significantly different among varying degrees of PH severity and between dogs with and without R‐CHF.

Conclusions and Clinical Importance

The RVEDA index can be used to evaluate RV size in dogs. It can provide additional information in dogs with PH and predict R‐CHF. Severity of TR is the main determinant of RV enlargement in dogs with PH.

Reference ranges and determinants of right ventricle outflow tract acceleration time in healthy adults by two-dimensional echocardiography

The right ventricular outflow tract acceleration time (RVOT-AT) has shown to progressively shorten with increasing degrees of pulmonary pressure. However, the physiologic ranges of RVOT AT are based on small sample sizes and have not been investigated regarding their determining factors. The aim of this study was to investigate reference values and determining factors of RVOT-AT in a large population of healthy subjects and by values described in the literature. In the first part of the study, 1029 healthy subjects (mean age 45.6 ± 16.0 years, 565 (54.7 %) females) were prospectively assessed by clinical examination including demography, vital signs and echocardiography. In the second part, we performed a pooled analysis of eight published studies describing RVOT-AT in healthy subjects (n = 450). Statistical analysis included the calculation of 5 % quantiles for defining reference values. RVOT-AT significantly but weakly correlated with age (r: -0.207; p < 0.001), body mass Index (r: -0.16), systolic (r: -0.158) and diastolic (r: -0.137) blood pressure, heart rate (r: -0.197) and left ventricular (LV) E/A ratio (r: 0.229) (all p < 0.001). No differences were found with regards to sex. In a synopsis of both prospective and literature-based data sets, RVOT-AT weighted means was 138.51 ms and the 5 % quantile was 104.7 ms (95 % confidence interval 98.2-110.1). This study delineates the range of RVOT-AT in healthy adults and it's determining factors. Our study is in line with the cut-off value stated by the European guidelines with an RVOT-AT ≤105 ms denoting abnormal values.

Echocardiography in pulmonary hypertension

PURPOSE OF REVIEW

Pulmonary hypertension is a progressive disease of the pulmonary vasculature characterized by increased vascular resistance and pressure overload of the right ventricle. This review aims to describe the diagnostic and prognostic role of echocardiography in pulmonary hypertension with particular consideration of relative strengths, weaknesses and new advances.

RECENT FINDINGS

Although right heart catheterization (RHC) remains the gold standard, echocardiography represents an accessible and feasible real-world tool for screening, differential diagnostic, follow-up assessments and risk stratification in pulmonary hypertension. In the context of clinical scenario and multimaging approach, echocardiography provides accurate measurements of pulmonary haemodynamics, either at rest and/or during exercise, and is particularly useful in ruling out secondary causes of pulmonary hypertension and/or detecting preclinical stages. The use of advanced noninvasive imaging techniques may provide additional information in assessing right heart structure and function.

SUMMARY

Advances in echocardiography and the multimodality imaging approach continue to provide new understandings and opportunities for the study of the right heart-pulmonary circulation unit in pulmonary hypertension.

Imaging the heart in pulmonary hypertension: an update

Noninvasive imaging of the heart plays an important role in the diagnosis and management of pulmonary hypertension (PH), and several well-established techniques are available for assessing performance of the right ventricle, the key determinant of patient survival. While right heart catheterisation is mandatory for establishing a diagnosis of PH, echocardiography is the most important screening tool for early detection of PH. Cardiac magnetic resonance imaging (CMRI) is also a reliable and practical tool that can be used as part of the diagnostic work-up. Echocardiography can measure a range of haemodynamic and anatomical variables (e.g. pericardial effusion and pulmonary artery pressure), whereas CMRI provides complementary information to echocardiography via high-resolution, three-dimensional imaging. Together with echocardiography and CMRI, techniques such as high-resolution computed tomography and positron emission tomography may also be valuable for screening, monitoring and follow-up assessments of patients with PH, but their clinical relevance has yet to be established. Technological advances have produced new variants of echocardiography, CMRI and positron emission tomography, and these permit closer examination of myocardial architecture, motion and deformation. Integrating these new tools into clinical practice in the future may lead to more precise noninvasive determination of diagnosis, risk and prognosis for PH.